BVA9501534
DOCKET NO. 92-20 752 ) DATE
)
On appeal from the decision of the
Department of Veterans Affairs (VA) Regional Office (RO) in
Albuquerque, New Mexico
THE ISSUE
Entitlement to service connection for post-traumatic stress
disorder (PTSD).
REPRESENTATION
Appellant represented by: Disabled American Veterans
ATTORNEY FOR THE BOARD
W. H. Wetmore, Counsel
INTRODUCTION
The veteran served on active duty from November 1966 to January
1969.
Service connection for PTSD was denied in a June 1988 rating
decision. The veteran was notified thereof in July 1988, and he
did not file an appeal. Subsequent treatment records, which
include diagnoses of PTSD, constitute new and material evidence
sufficient to reopen the veteran's claim.
The Board of Veterans' Appeals (Board) received this case on
appeal from an October 1990 rating decision. The Board remanded
this case to the RO in April 1993.
CONTENTIONS OF APPELLANT ON APPEAL
The veteran contends that he has PTSD due to the combat he
experienced in Vietnam.
DECISION OF THE BOARD
The Board, in accordance with the provisions of 38 U.S.C.A.
§ 7104 (West 1991), has reviewed and considered all of the
evidence and material of record in the veteran's claims file.
Based on its review of the relevant evidence in this matter, and
for the following reasons and bases, it is the decision of the
Board that the preponderance of the evidence is against the claim
of service connection for PTSD.
FINDINGS OF FACT
1. The veteran served in one campaign in Vietnam.
2. The veteran does not have PTSD.
CONCLUSION OF LAW
The veteran does not have PTSD that is the result of disease or
injury incurred in or aggravated by service. 38 U.S.C.A.
§§ 1110, 5107, 7104 (West 1991); 38 C.F.R. §§ 3.102, 3.303, 3.304
(1993).
REASONS AND BASES FOR FINDINGS AND CONCLUSION
The veteran's claim is well grounded under 38 U.S.C.A. § 5107
because it is plausible in that the record does show that some VA
doctors have diagnosed him as having PTSD. The Board remanded
this case in April 1993 to confirm the diagnosis and the record
now shows that the current diagnosis is supported by a review of
the record and it is a considered opinion. Therefore, further
development is not in order and there is no current duty to
assist the veteran in the development of his claim. 38 U.S.C.A.
§ 5107; Littke v. Derwinski, 1 Vet.App. 90 (1990).
The service and postservice medical evidence of record, covering
the period through the veteran's treatment at a VA medical center
in January 1987, does not include any diagnoses of PTSD. Those
records also do not include any references to stressful events in
service.
When he was treated at a VA medical center in December 1987, the
veteran had been referred for a work-up for PTSD. His major
problem over the years since Vietnam had been drinking as much
alcohol as he could hold. He initially reported having been shot
in the right lower extremity during a combat mission; however, he
amended that story and admitted that he had accidentally shot
himself (the record shows that he accidentally shot himself in
June 1968). He claimed survivor guilt over shooting civilians.
Diagnostic testing was evaluated as positive for PTSD and that
disorder was diagnosed during this period of hospitalization.
The veteran was seen at a PTSD treatment facility from April to
May 1988 where the diagnosis was PTSD. He did not comply with
the program and withdrew.
At a June 1988 VA examination, the veteran was a poor historian.
He complained of memory problems, frequent awakening and
nightmares. He said that he had been wounded in Vietnam and then
amended this story and admitted that he had accidentally wounded
himself. He said that his worst experience in Vietnam was
catching a virus. He stated that he had received a combat
infantryman's badge and a Purple Heart (the record does not
confirm these claims). The diagnoses included PTSD.
When he was treated at a VA medical center from January to
February 1990, the veteran said he had noticed a worsening of his
PTSD symptoms, including nightmares four to seven times a week,
intrusive thoughts of Vietnam and extreme irritability at
unexpected noises or events. The diagnoses included PTSD. That
disorder was also diagnosed during treatment from March to April
1990 and from April to June 1990 at VA facilities.
When he was seen at a VA medical center on two occasions in
August 1991, the veteran voiced no complaints of stress
associated with his military experiences. The diagnoses did not
include PTSD.
During treatment at a VA medical center in August 1993, the
veteran said he had been treated for PTSD. The clinical findings
did not lead to diagnoses which included PTSD. The diagnoses
during his treatment at a VA medical center in September 1993
also do not include PTSD.
The RO received a two page statement in March 1994 from the
veteran setting forth his military activities while in Vietnam.
At a VA examination in March 1994, the veteran complained of
difficulty adjusting to others, including his family. His other
complaints included difficulty sleeping. The claims file and
hospital chart were reviewed by the examiner. The diagnoses did
not include PTSD. In the discussion, the examiners opined that
the veteran's other problems "profoundly overshadow any
indication of [PTSD] if it is indeed present." It was felt that
the record did not support a diagnosis of PTSD and that further
neuropsychological testing would not change the diagnosis.
The Board finds that the current medical conclusion is that the
veteran does not have PTSD. Although this diagnosis was applied
for several years, the record does not provide support for it
now. The Board particularly notes that the veteran has misled
some examiners in relating what happened to him in service and in
the awards he received. The fact that he is a poor historian may
be the explanation for this but the earlier diagnoses of PTSD are
shown to be possibly based on inaccurate information from him.
The current conclusion that he does not have PTSD is based on a
review of the record, including hospital notes. Thus, the Board
feels confident in relying upon the current conclusion by the two
psychiatric examiners. It follows that service connection is not
warranted. Based upon the conclusions and diagnoses recently
reached by the psychiatric examiners, the failure to refer this
case to the United States Army and Joint Services Environmental
Support Group does not militate against a decision on the merits
at the present time. While the veteran has provided some
information, albeit most of it vague, concerning Vietnam
stressors, clinical evaluation has resulted in a conclusion that
psychiatric disorders not here at issue "profoundly overshadow
any indication" (emphasis added) of PTSD. This unequivocal
conclusion, coupled with the misstatements by the veteran to
examiners in the past, leads to the conclusion that the failure
to take further action to confirm the presence of alleged
stressors is no more than harmless error.
ORDER
Service connection for PTSD is denied.
BARBARA B. COPELAND
Member, Board of Veterans' Appeals
The Board of Veterans' Appeals Administrative Procedures
Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___
(1994), permits a proceeding instituted before the Board to be
assigned to an individual member of the Board for a
determination. This proceeding has been assigned to an
individual member of the Board.
NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West
1991), a decision of the Board of Veterans' Appeals granting less
than the complete benefit, or benefits, sought on appeal is
appealable to the United States Court of Veterans Appeals within
120 days from the date of mailing of notice of the decision,
provided that a Notice of Disagreement concerning an issue which
was before the Board was filed with the agency of original
jurisdiction on or after November 18, 1988. Veterans' Judicial
Review Act, Pub. L. No. 100-687, § 402 (1988). The date which
appears on the face of this decision constitutes the date of
mailing and the copy of this decision which you have received is
your notice of the action taken on your appeal by the Board of
Veterans' Appeals.